HomeMy Public PortalAbout5940 LOMA AVE_Sewer__ DE Tp
OF CO YG�R SEWED-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS A3NGF-T S
WILLIAM J. FOX, COUNTY ENGINEER BUILDING �
ADDRESS
15" /�� �, ♦��G
FOR APPLICANT TO FILL IN LOCALITY
BUILDING /�tNEAREST
DDRESS �/ /� �� � � CROSS ST.
A
LOCALITY
''Alf DISTRICT N0. SERIAL NO. PERMIT NO.
,� A 16-9 c►0/ 110 9 0 S
NEAREST �/2 / 1 A '�
CROSS SL [_.6// RECEIVED BY Ready for Inspection DATE ISSUED
OWNER �'T-�'St & , \ W ��
MAIL
ADDRESS U E ZONE OCCUPANCY BK MAP PG
.V4 _ •
CITY TEL.NO.
CONTRACTOR (r"� 6/1s/ CO.IMP.NO. f
ADDRESS Yrl�v Ga.6. eI'C�, i JOB.N0.
CITY s , � G TELAO. � ® 6�of 7 TRUNK PERMIT NO.
STATE
�j `f G• `y' �®
REGISTRATION N0. COUNTY-e� ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. :3 &
/ STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT t9 INDUSTRIAL
WASTE APPROVAL sh
SIZE OF LOT NO.OF BLDGS. CHARGES.
NOW ON LOT
USE
BUILDINGS � /` ��
/_J Lti� ( CONNECTION C-FrkRGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER .@ $ 3.50 RECEIPT NO. DA I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER I.00 B
ALTER OR REPAIR EXISTING NO- I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_AND/OR DISPOSAL SYSTEM - 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
4S' �
PITS AND/OR DRA4NFIELD 2.00 STATIONDEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 s-1. v 01 s� MANHOLE REFERENCE
pumLOWER
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ I I 00
AUTHORIZATION TOTAL FEE 2.00
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO-CONNECT THE ABOVE DESCRIBED EXISTING_ APPROVALS INSPECTOR'S SIGNATURE DATE
.DWELLING TO�THE',P\UB-LIC SEWER —
SIGNED THIS............ vDA OF.C _-.._____ - Iq_f •_ NEW HOUSE SEWER
_.. .� -�s
.-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ...-_.. ..._...-___..___..._.._.._......_.._. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS............. AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS JRLE
CESSPOOL DRYWELLEl
CATION AND STATE-THAT THE ABOVE IS CORRECT AND
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATEALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISDISCONNECT PLUG ANDAND/OR LICENSED AS REQUIRED BY LOS ANGELES CABANDON HOPLUGANDAND STATE OF CALIFORNIA OR THAT I AM THE LEGALEROF THE ABOVE�CRIBED RESIDENTIA�TBACKFILL SEPTIC TANKS
SIGNATURE �.rSEEP.PIT(S)E] CESSPOOLS 0, 3'23.OF PERMITTEE - - ".._.. - -.. l
Mato J'p
76AG42A 663 7/53
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